By Kathleen G. J. Charters and Lawrence I. Charters
Presented before the 1980 Conference of the Commissioned Officer’s Association, sponsored by the Commissioned Officer’s Association, U.S. Public Health Service, Houston, Texas, May 26-29, 1980.
Abstract
Lacking the economic or political clout of hospital surgical, medical, pharmacy or financial and clerical departments, nursing is usually the last department to be considered for computerization. Yet nursing is in constant daily contact with all other departments and generates a large portion of their records. At present, different departments usually have their own specialized, mutually incompatible medical information systems (MIS) and communication and coordination is a constant problem. A centralized, generalized computer-based MIS should eliminate these problems and should logically be based upon the most central and general of all the health professions: nursing.
Past and present MIS will be critiqued, and a comparison of these systems with a nursing based MIS will be offered. Proper integration of nursing and computer technology offers revolutionary benefits for all branches of the health Professions and such benefits will be explored.
Most Medical Information Systems (MIS) now in use are based upon systems originally designed to meet commercial business needs. If you were to pick up virtually any computer magazine and answer an advertisement for “medical software,” you would receive information on packages which would include Accounts Payable, Accounts Receivable, Inventory, General Ledger, and other very non-medical applications.1 The reasons for this trend are numerous and varied, yet the end result is fairly standard: most MIS are usually no more than fancy business packages and could easily be adapted for use by banks, real estate agencies, or supermarkets.
Even the best MIS currently in use tend to ignore nursing’s role within the medical system. Computer systems are available for use by almost every department of a hospital except the nursing department. Medical records, pharmacy, x-ray, clinics, medicine, surgery and supply departments are routinely automated, yet the most central of all departments — nursing — rarely even has access to systems in use by other departments. Most of the basic records and information generated in a hospital are routed through nursing, yet little or no consideration is given to automating this flow. As a result, modern nursing often seems as much clerical as medical.
Since nursing is the most central department of a hospital, it is only reasonable that a useful MIS be designed to meet its basic requirements. Patients are, after all, hospitalized in order to receive nursing care, so it seems appropriate to build a system that would free the nursing staff to provide as much of this care as possible.
As almost all hospital records are filled out, written up, or otherwise pass through the nursing department, it is essential that any system meet the needs of both the nursing department and all other departments which use such records. In the past, attempts have been made to meet such requirements bu linking all hospital functions, and even several hospitals, into one massive computer network. Often the computer equipment is not even under the control of the hospital(s) using it and is almost never operated by personnel trained in the medical sciences. The end result is a system that requires all users to “share” computer time, often involving time delays far greater than would have been necessary were the hospital using manual systems. Another result is that the computer system, again reflecting both a business orientation and a shared-use concept, fails to adequately meet the needs of any of its hospital users.
One of the more ironic aspects of computerization is the proliferation of paperwork. Because of the business and financial biases of the computer industry, computers are designed to generate statistics, forms, reports, and other forms of paper with great speed. Printers are on the market with the ability to print sheets of paper faster than a man can run. A mile-long roll of paper can be coated with small print, 132 columns or more across, in less than three minutes. This technology, combined with the traditional business sense of security in the printed word, have inundated our society in computer printouts. Hospitals, purchasing business-based computer systems, have fallen victim to this plague, and are being buried in forms by the building full.
Yet neither the business bias nor the paper deluge is necessary. Using microcomputer technology and the computer’s (usually wasted) ability to store staggering amounts of information in a small space, almost any nursing department, and, by extension, almost any hospital, can be automated at little cost.
Little cost means precisely that. This study was, itself, composed
Microcomputers are, in fact, the key to a useful MIS. Due to their low cost and increasing speed and flexibility, microcomputers are the most practical building blocks for a hospital MIS. Dozens of microcomputers can be purchased and linked together to form a complete system, replacing, in the process, countless typewriters, adding machines, calculators, and computer terminals. Unlike a time-sharing system, an MIS based upon microcomputers would also provide complete freedom from time restraints and backlogs, for every station in the MIS would have at its disposal a full computer, and not just part of a computer located at a remote site.
As currently established, an MIS for a medium-sized hospital (200 beds) using a time-shared network would cost the hospital roughly $500,000.00 per year for lease of the system.3 The hardware for an MIS based upon microcomputers could be purchased, outright, for roughly a fifth of this cost.
This point is best illustrated through a proposal for an MIS for the U.S.P.H.S. Hospital, San Francisco, currently a 260-bed facility. The prices given are
The nursing department has responsibility for eight units: four nursing floors, three specialty care units, and the nursing office itself. Each floor would require two computers, such duplication being necessary in order to provide backup in time of failure and also in order to overcome the “herd” instinct — everyone wanting to use the computer at once. Similarly, two of the three specialty care units would require two computers, and one unit could get by on a single computer. The nursing office would require two computers to coordinate all activities and provide for central services for a total of fifteen computers.
Coordinating these computers would be a multiplexer, a disk-based information pool, and a videotape backup system for the disks. The system would look like this:
- Four nursing floors — each with two computers;
- Primary care/emergency room — two computers;
- Recovery room/surgical intensive care — one computer;
- Intensive care/coronary care — two computers;
- Nursing office — two computers, disk information system, videotape backup, multiplexer.4
The equipment and costs:
- Fifteen 64K Radio Shack TRS-80 Model II computers at $3899 each;
- One Corvus 11 T Primary Disk Drive at $4695;
- Three Corvus 11 TA Secondary Disk Drives at $3195 each;
- One Corvus Mirror Videotape Disk Backup at $695;
- One videotape recorder (any brand) at $1000.00;
- One Corvus Constellation MultiPlexer at $650.00;
- Fourteen Corvus Constellation interfaces at $260.00 each.
Total hardware cost: $69,165.00
Such a system would have staggering capabilities. On-line system capacities are:
- RAM (Random Access Memory) — 983,040 bytes
- Floppy disk storage — 7,290,000 bytes
- Disk storage — 40,000,000 bytes
Removable storage — floppy disks and videotape cartridges — is virtually unlimited, governed only by how many floppy disks and videotapes are purchased.5
The usual question to ask at this point is: all this power is wonderful, but what can be done with it? An accurate answer to any question asking what a computer can do is to say “nothing.” When you turn on a computer, it does nothing. On the other hand, depending upon what you tell it to do, a computer can do almost anything. In the field of nursing, the number of things that a computer can do, and should do, is astonishing.
One of the most time-consuming tasks for any nursing department is scheduling. Nursing is about the only department that is expected to run with a reasonable staff every single hour of every day of the year. Trying to fill time slots with people who require sleep, vacations, time off, professional leave, and other obstacles to easy scheduling is not an easy task. If staffing is done manually, it usually requires between ten and twenty percent of the total time each head nurse has to devote to the job. Often scheduling also involves the nursing director or assistant director, and accordingly takes away time they could devote to other tasks. In some hospitals, nurse staffing is such a chore that entire administrative departments, complete with their own staff, are necessary in order to plan usable schedules.
Yet staff scheduling is a task that is ideally suited to automation. Once the initial information is fed into the computer (nurse position, part or full time, shift preference if any, amount of leave available, etc.) the computer can generate a complete schedule in minutes, either floor by floor or for the hospital as a whole. Scheduling can also be done for weeks or months in advance, and schedules can be modified at any time to reflect changes that may have occurred. Vacancies can even be “scheduled,” since the computer can generate ordered lists of staff members to be called in case of absences. Staff members can then be made aware of what times they will be on call, and what times they will not. Such knowledge invariably increases staff morale. Most significantly, computerized scheduling requires little or no professional staff time. A single clerk, such as a timekeeper, can maintain the entire system with almost no training, and still have time to perform other clerical duties.6
Another task that constantly plagues nurses, particularly those with administrative duties, is report writing. For whatever reasons, written reports seem to be required for almost everything, and hatred for written reports is exceeded only by hatred for writing reports. Yet a microcomputer, equipped with a word processing package, can bring report writing to the level of art. A computer’s screen can be transformed into a magic sheet of paper, and letters, words, paragraphs, and whole pages can be added, deleted, or modified at will. “Word processing” is a poor term to describe this magic, since even a poor typist can churn out perfectly typed reports, without ever having to resort to erasures, strikeovers or retyping. Furthermore, all of this can be accomplished without any knowledge of how a computer, or even a typewriter, works. Word processing also makes it possible to follow a consistent style in all reports, making such reports more useful and readable. The savings in paper, correction fluid, ulcers, and increased productivity will usually pay for the cost of a word processor in just a few months.7
Message transmittal is also a task best left to a computer. In the system proposed, each of the fifteen computers in the network could send requests, notes, demands, and gossip to any or all of the other computers, enabling far more detailed information to be transmitted than is possible with traditional systems. Rather than attempt to get someone on the phone for a complex message, the computer system could route a message, instantly, to wherever or whomever it was needed. Dietary changes could be sent, results of consults could be routed, and responses could be transmitted through the network. Announcements can also be made over the computer, quickly and silently, freeing the traditional audio public address system for other uses. Some examples:
- All head nurses: floor Patient load reports are due by 15:00.
- Nancy Smith. Contact Adam Jones, ICU, stat. Bring notes on where you want to go for dinner.
- John Doe: Dietary reports that Mr. Ajihi cannot have a goat. It is too high in protein, and not available from stock.
- Night shift: The poison center reports that Mr. Collins swallowed bourbon, not arsenic. The full report will follow.
- Class: Susan Miller will offer an in-service on warts in room 2056 at 07:30.
- 3 West: Physical therapy is waiting for Mr. Johnson. His appointment was at 10:30.
Confidential messages can be sent also, using the traditional codes long used for audio paging. Additionally, such a message system can be used at night, when most audio paging systems are disconnected in order to avoid disturbing patients.8
Care plans can be easily drafted on such a computer system. Basic information can be drawn by the computer from the Patient’s admission report (name, age, floor assignment, etc.). Details can then be added by the nursing staff, with the computer prompting to ensure that all items are covered. Each diagnosis would prompt a listing of standard nursing interventions which could then be individualized by adding to or deleting from this routine.9
Potentially the most significant application of a nursing MIS is in the area of medications. Present manual systems suffer from a variety of limitations, among them:
- Physician orders are illegible;
- Physician orders are incomplete;
- Medication orders are transcribed in a variety of places, using a variety of systems;
- Due to the proliferation of medications, it is not always possible to know whether a medication order is reasonable or whether it should be questioned to ensure the patient’s safety;
- Auditing of medication records is often incomplete;
- “Permanent” records often aren’t, since it is possible to insert, remove, erase, or deface entries in order to cover up errors;
- Deviation from policy and procedure is possible, increasing the possibility of medication errors;
- There is no fail-safe way of preventing errors of omission.
For example, a physician can write medication orders directly on the computer screen using a light pen to choose a drug from a menu reflecting the hospital for formulary. Once a drug is indicated, the physician may be prompted to indicate the amount, the route of administration, and the frequency of administration. If the order is incomplete or if the amount or form indicated is not within pharmacy guidelines, the physician can immediately be so informed. The order might then be evaluated for possible drug interactions with other medications the patient is currently receiving, and this information will also be conveyed to the physician. In order for the transaction to be completed the physician must identify himself. The transaction then becomes a part of the permanent medical record and can be superseded by an updated order, but the original order will remain on the record.
The order may then transmitted to the pharmacy, and to the patient’s on-line medex. When medications are due to be given, this information is listed. The nurse administers the medication, or notes the reason why the medication was not given. This information is entered into the computer, updating each patient’s on-line medex. Any medication not noted as given is listed hourly until administered or a reason for not giving it is entered. An entry may be corrected, but the date and time of correction become part of the permanent record.
Medications due to be rewritten can be flagged as such. Medication review can be readily accomplished as a current record is always available. A variety of audits may be performed since the computer is capable of searching medical records for keywords (including dates and names) or phrases.
The capability to search records for keywords or phrases is useful in other ways as well. Preparation of documentation for Joint Accreditation visits is vastly simplified. Nursing audits, staffing levels, patient workload indexes, staff development activities, etc., are all readily available and quickly searched for pertinent information. For example, when a nurse joins the staff a file is created listing pertinent personal data and educational background. Attendance at in-service and external training activities can be added to this record with a minimum of effort. A yearly summary may then be generated showing the amount of training per individual, or category, or attendance data for a given event, or group of events.
The proposed nursing MIS should not only generate a statistical analysis of training activities but should also be a medium through which such activities are carried out. A computer can interact with the user, and this has great potential for programmed studies and simulations. A nurse may choose an intervention and the consequences of that intervention can be predicted; another course of action can then be proposed and the consequences of that intervention predicted. In this manner, many alternatives may be explored and the most healthful course of action chosen. At the end of the training exercise, a summary of the learner’s performance can be given, and further learning activities suggested.
Similarly, the MIS can be used for Patient education. Since the computer is viewed as an impersonal device, several researchers are investigating the potential uses of computers for medical and mental health screening. Preliminary results seem to indicate that people, in general, are far more willing to discuss intimate details with an inanimate computer than with a flesh and blood specialist. This same sociological phenomenon can be used to great advantage in patient education since it is entirely possible that a programmed course of study using a computer might prove far more fascinating, and involve far less patient resistance than a similar program overtly run by a health professional.
Because of the flexibility of microcomputers, these are just a few of the many tasks which can be automated. Additional chores can be added at any time, without affecting total system performance in any way, since each computer in the network operates independently. Eventually, hospital personnel will be able to carry hand-held computer terminals which can be used for making notes, passing messages, acting as locators, calculators, and typewriters, and in general, replacing almost every piece of office equipment but the trash can and the chair.10 This day is not far off, and the PHS, as the official health care branch of the U. S. Government, should aggressively develop a nursing MIS. The technology and talent are available, the cost is modest, and the benefits — improved staff utilization and better health care — are worthy.
Notes
1 The authors of the present study conducted a non-scientific survey to discover what kind of medical software was commercially available. Advertisements in major computer magazines promoting ”medical software” were answered using business reply coupons. Out of 71 responses, all 71 packages offered were, in fact, business packages and not medical packages. Only one of the 71 packages had even a vague relationship to medicine; this package contained a subprogram which would alphabetize patient files.
2 This report was drafted, composed, rewritten and printed by a Radio Shack TRS-80 Model I Level II microcomputer using Radio Shack’s Script word processing program. It was printed on Radio Shack’s Line Printer II, a dot-matrix printer with a speed of 100 characters per second — roughly 900 words per minute — and capable of printing on sheets of ordinary typing paper as well as standard computer forms. In addition to word processing, the authors have used this computer to play chess (it consistently beats both of them), do historical research, write and play music, draw pictures, design education programs, print and mail Christmas cards, compile and evaluate advanced statistical studies, write science fiction, mail out change of address forms, and automatically file thousands of personal and financial records. Though marketed as a “home” or “personal” computer the authors are currently developing an MIS designed to run on this inexpensive and flexible machine.
3 As there is, at present, no operational MIS which a 200-bed hospital could afford, the $500,000.00 figure is mostly theoretical. This figure covers lease of terminals and other equipment at the hospital as well as computer time and service at the site operated by the MIS vendor but does not include such things as the lease of phone lines for data transmission, service of equipment, etc. In essence, this figure represents the rental of the software, the computer time, and the means to access both.
4 Each of the fifteen computers would have 64,000 characters of user memory and have a built-in floppy disk drive with 480,000 characters of memory. Each computer could run BASIC, FORTRAN, COBOL, PASCAL, or any of the other common computer languages, and could do so independently of any of the other computers in the system. The multiplexer is designed to coordinate the exchange of information between the various computers in the network. The “hard disk” system is necessary in order to provide a huge, common storage area for information used by the various elements of the network. The videotape backup system is necessary to provide inexpensive archival storage of information which is no longer in use. The network could eventually be expanded to include up to 64 computers, and printers, plotters, digitizers, and other odd devices could be added as necessary. The proposed system could even be hooked up, via phone lines, to similar systems at other hospitals, or to regional information networks.
5 Translated into English, a byte is equal to one character — a number, a letter, or a space. Figuring seven characters for the average word and four hundred words to the typewritten page (this paper averages only two hundred words per page), a single floppy disk with a 486,000-byte capacity could hold 174 pages of information. As each computer in the proposed system has one floppy disk drive built-in, the entire system of fifteen computers could hold 2,610 pages of information. Adding in the hard disk storage of 40 million bytes, the system could hold 16,900 pages of information at one time. Any or all of this information can be stored for permanent records at any point, so the capacity of the system could best be described as unlimited.
6 The authors of this paper are presently designing a nurse staffing program that can run on their own computer, a smaller and less talented version of the machine proposed for the MIS. Staffing programs are also available from commercial sources.
7 A word processing package can be used for other purposes, of course. If a letter must be sent to all members of the staff or a bid to several companies, a word processor can be used to construct the basic letter and then print as many copies as necessary. The result is far different from a form letter, since each copy is, in fact, a typed “original,“ and can be personalized with individual names and other unique references. With reference to productivity, it might be noted that the authors of this paper type, on a typewriter, at only 30 words per minute, but on their computer, they can usually manage 50 to 60 words per minute.
8 Such a message system can also be used for sending printed documents. Small 40 column printers are available which can print on ordinary adding machine paper, almost any kind of short report desired. Lab slips can be routed, via computer, down to the lab, and results can be sent back and printed, ready for insertion into the patient’s record. Such a system has several distinct advantages: slips cannot be “lost,” can be acted upon in the exact order of receipt, can be sent back and forth instantly, and will almost always be properly filled out. Since the computer will prompt the user to fill in all the blanks, and since the information will be typed, and, thus, legible, there won’t be any delays based upon illegible or incorrectly filled out lab requests.
9 Consider the patient with Degenerative Joint Disease admitted for total hip replacement. Routine tests would be scheduled, a pre-operative protocol initiated, the surgery would be scheduled, and a post-operative protocol based upon achievement of performance criteria would be generated through the MIS.
10 Consider the potential of a hand-held computer that would give the patient’s name and list the medications to be administered.
Computers in Nursing: Select Bibliography
Ballantyne, Donna J. “A computerized scheduling system with centralized staffing.” Journal of Nursing Administration 9 (March 1979): 30-45.
Cornell, Sudie A., and Carrick, Albert G. “Computerized schedules and care plans.” Nursing Outlook 21 (December 1973): 781-784.
Gagne, James. “Softdoc: A proposal for a medical software network.” In The Best of the Computer Faires, Vol. V: Conference Proceedings of the 5th West Coast Computer Faire. Edited by Jim C. Warren. Woodside, CA: Computer Faire, 1980.
Institute for Electrical and Electronic Engineers. “Information systems for patient care.” Computer 12 (November 1979): 4-52.
International Business Machines. Nurse Scheduling Systems, Fairview General Hospital; Program Description / Operations Manual. Program Number 5796-ANA. White Plains, NY: International Business Machines, 1977.
Jelinek, Richard C., and Zinn, Tim K. A Nurse Scheduling and Allocation System in Operation. Chicago: The MEDICUS Corporation, 1972.
Later, Judith E., ed. Computers for Pharmacy: A Guide to Their Selection and Use in Community Practice. Washington, DC: American Pharmaceutical Association, 1978.
Matheosian, Richard S., ed. Current Medical Information Systems. San Francisco: University of California San Francisco Technical Report #22, 1976.
Spohr, Mark H. “The computer in the practice of medicine: an overview.” In The Best of the Computer Faires, Vol. VI: Conference Proceedings of the 5th West Coast Computer Faire. Edited by Jim C. Warren. Woodside, CA: Computer Faire, 1980.
Stimson, David H., and Stimson, Ruth H. Operations Research in Hospitals: Diagnosis and Prognosis. Chicago: Hospital Research and Educational Trust, 1972.
“TRS-80 and Apple top survey of doctors using micros,” Personal Computing, May 1980, pp. 12-13.
The United States. Congress. Office of Technology Assessment. Policy Implications of Medical Information Systems. Washington, DC: Government Printing Office, 1977.
The United States. Department of Health, Education and Welfare. Public Health Service. Public Health Service Automatic Data Processing Systems Security Program. Washington, DC: Government Printing Office, 1979.
Wagner, Harvey M. Principles of Operations Research: With Applications to Managerial Decisions. 2d ed. Englewood Cliffs, NJ: Prentice-Hall, 1969.
Warner, Michael D. “Scheduling nursing personnel according to nurse preference: a mathematical programming approach.” Operations Research 24 (September-October 1976): 842-870.
Computers, Robots, Cyborgs, and Health: A More Enjoyable Bibliography
Asimov, Isaac. The Caves of Steel (1953).
_____ . I, Robot (1950).
_____ . The Naked Sun (1957).
_____ . The Rest of the Robots (1964).
Brunner, John. Stand on Zanzibar (1968).
Caidin, Martin. Cyborg (1972).
Clarke, Arthur C. 2001: A Space Odyssey (1968).
Clifton, Mark, and Riley, Frank. They’d Rather Be Right (1957).
Compton, D. G. The Steel Crocodile (1970).
Gerrold, David. When Harlie Was One (1972).
Heinlein, Robert A. The Moon is a Harsh Mistress (1966).
Hogan, James P. The Genesis Machine (1978).
______ . The Two Faces of Tomorrow (1979).
Ing, Dean. Soft Targets (1979).
Jones, D. F. Colossus (1966).
______ . Colossus and the Crab (1977).
______ . The Fall of Colossus (1974).
McCaffrey, Anne. The Ship Who Sang (1969).
Orwell, George. 1984 (1949).
Piper, H. Beam. The Cosmic Computer (1963).
Pohl, Frederik. Beyond the Blue Event Horizon (1980).
______ . Gateway (1977).
______ . Man Plus (1976).
Ryan, Thomas. The Adolescence of P-1 (1977).
Saberhagen, Fred. Berserker (1967).
Spinrad, Norman. Bug Jack Barron (1969).
Vinge, Joan D. Fireship (1978).